PRINCIPLES OF DECONTAMINATION 10

Medical Directors Directorate

Date of production/Last update
Date of last review
Date of next review
Lead reviewer

Infection Control Manual

January 2009
January 2012
January 2013
Ann Jack ICN

10

PRINCIPLES OF DECONTAMINATION

CONTENTS
Page
10.1

Decontamination overview

10.2

Cleaning

10.3

Disinfection

24

10.4

Sterilisation

28

10.5

Documents

33

Appendix 1

35

Page 2

Chapter 10 Decontamination
10.1 Decontamination Overview
10.1.1 Introduction
Micro-organisms can be transmitted to people from instruments, equipment and/or
the environment.
Where a piece of equipment is used for more than one patient it must be
decontaminated following each and every episode of use and prior to being sent for
service or repair, to ensure the safety of both patients and staff.
The decontamination process makes medical devices safe for healthcare staff to
handle and for use on patients
The level of decontamination required is dependent on what the equipment is used
for and the level to which it has been contaminated.
The term decontamination refers to a process, which removes or destroys
contamination. Consequently micro-organisms (or other contaminants) are prevented
from reaching a susceptible site, in sufficient numbers necessary to initiate infection
or any harmful response.
These are the process to be followed to initiate correct steps in performing
decontamination:

Cleaning: physical removal of contaminants including dust, soil and organic

matter, along with a large proportion of micro organisms. (Drying will cause a
further reduction). This Process is essential prior to disinfection and
sterilisation (refer to section10.2)

Disinfection: Utilising heat or chemicals to reduce the number of viable

micro- organisms to a level which is not harmful to health (but not all viruses
and/or bacterial spores). (Refer to section10.3)

Sterilisation: Renders the object free from viable micro-organisms, including

bacterial spores and viruses (refer to section 10.4)

The purpose of this section of the manual is to ensure a quality service which takes
into account a safe method of decontamination of equipment and items used in
patient care, thereby helping to provide and maintain a safe, healthy working
environment
Important Note: All decontamination procedures should be undertaken by a qualified
trained and equipped member of staff, wearing personal protective equipment.
Responsibilities
The NHS Scotland Code of Practice for the Local Management of Hygiene and
Healthcare Associated Infection (Scottish Executive, 2004) supports action to reduce
the risk of healthcare associated infection (HAI) for patients, staff, visitors and wider
public at local level. Success is dependent on a change in culture where infection
control is truly everybodys business with a clear focus on the importance of good
hygiene, infection control practice and education.
Page 3

Service Users, staff and visitors each have an individual responsibility to ensure a
safe, effective and clean medical and surgical devices that are to be used on patients
within the healthcare setting. All staff have a responsibility within the organisation
and must support its commitment to HAI control and reduction. See NHS Fife
Infection Control Manual Introduction: Responsibilities
Incident reporting
Where there has been a potential or actual risk in relation to the decontamination of
surgical instruments and other patient associated equipment which exposes staff or
others to infection or injury, the NHS Fife Incident Management Policy G9 should
be followed and an NHS Fife Incident/Near Miss Report Form completed. Staff
should report any issues arising in relation to the use of cleaning solutions, e.g. skin
reactions
The decontamination process required is commonly specified as one of three
levels (based on the classification system first proposed by Dr E H Spaulding).
Risk

Application

High

Item in close contact with a break in the skin or mucous

membrane or introduced into a sterile body cavity
Item in contact with intact mucous membranes, body fluids
and particularly after use on infected patients or prior to use
on immuno-compromised patients.
Items in contact with healthy skin or mucous membranes or
not in contact with patient.

Medium

Low

Recommendatio
n
Sterilisation
Sterilisation or
disinfection
cleaning

Some high-risk or intermediate-risk medical devices are not able to be heat sterilised
and require high level disinfection between patients use i.e. fibre-optic endoscopes.
Refer to section?
10.1.2 Single Use Equipment
Single use means that the manufacturer:

Intends the item to be used once and then discarded

Considers the item unsuitable for use on more than one occasion.

Has insufficient evidence to confirm that re-use would be safe.
It is essential that equipment intended for single use is not reprocessed. If a
single use item is reused/reprocessed then NHS Fife and the user is legally
liable for that particular product.
Single use items/products are denoted by:

Page 4

10.1.3 The Decontamination of invasive medical healthcare equipment prior to

inspection, service or repair

Equipment being sent for maintenance or repair must be correctly
decontaminated to remove or minimise the risk of infection to staff
subsequently involved in handling the equipment.

A declaration of decontamination status certificate should be completed
before sending items for repair or maintenance. See Operational policy E10
and Appendix 1 (page 35).
Good practice points

The decontamination process chosen must be effective for the device
being re- processed and the procedure that will be undertaken.

Ensure the decontamination agents used are compatible with both the
devices and the reprocessing equipment.

Decontaminate devices in accordance with the manufacturers instructions

Ensure appropriate decontamination facilities are available for the process
to be undertaken

Ensure any decontamination equipment used is fit for purpose and
regularly maintained, validated and tested.

Appropriate Personal Protective Equipment (PPE) must be worn when
undertaking decontamination activities.

Staff undertaking decontamination activities should be trained for the
tasks they undertake.

Never re use single use equipment

Standard infection control precautions should be adhered to at all times.

Workflow should proceed from dirty to clean

Sterile and sterilised devices must be segregated and stored in clean dry
conditions, outwith the decontamination area.

Page 5

10.1.4 Choosing a Decontamination Process

Choosing the Appropriate Decontamination Process

In accordance with Spaulding Risk Classification
Are disposables available?
NO

YES

Choose level of decontamination required:-

Level of Infection Risk

HIGH

Level of Infection Risk

MEDIUM

Sterilisation (or high level

disinfection if heat labile)

Disinfection or Sterilisation

Is item able to withstand heat

sterilisation?

YES sterilise

NO High
Level chemical
disinfection

Can equipment withstand heat

disinfection?

YES
Washer
Disinfect
or

Non- Chemical
Disinfection

Use disposables
Level of Infection Risk
LOW
Clean

Can equipment withstand

automated cleaning?

YES use automated

cleaning if available.

NO Can item be
immersed?

If not available then

YES use
immersion
cleaning method

NO use non
immersion
cleaning method

Always ensure that the manufacturers guidance is considered before purchasing equipment.
Page 6

Chapter 10 Decontamination
10.2.1 Cleaning
Definition

CLEANING is a dirt removing process, using liquid detergent and warm water. This process
removes a high proportion of all micro-organisms.
It is essential for the removal of organic matter, grease and lubricants, which might otherwise protect
organisms from additional decontamination processes such as disinfection and sterilisation.

Good Practice Points

When carrying out any decontamination process personal protective equipment
must be worn.

Cleaning is the first and most important step in any decontamination process and is an
essential prerequisite to ensure effective disinfection or sterilization of equipment.

Follow the manufacturers recommendations or guidance provided with regard to the
amount to be used, dilution and contact time and to always make cleaning solutions at
time of use.

Wherever available, the use of mechanical cleaners such as washer disinfectors and
ultrasonic washers is preferred to the manual cleaning of items.

The cleaning method used should be assessed to ensure the effectiveness of the
cleaning process without damage to equipment.

Cleaning can be achieved by either manual or automated methods.

Decontaminate hands prior to commencing the process and donning PPE

Wear the correct PPE for the task being undertaken i.e. gloves, aprons and eye
protection

Ensure cleaning solutions are made up freshly when they are required and not preprepared in advance

If disinfection is required, this must be carried out after thorough cleaning rinsing and
drying has been undertaken

Dispose of cleaning materials and PPE as per NHS Fife Waste Policy.

Decontaminate hands following the cleaning process.

All documentation to record item being reprocessed and the method used is completed at
the time reprocessing has occurred.

General principles:

Cleaning and thorough rinsing should always precede any attempt to disinfect or sterilise

Cleaning can be achieved by either manual or automated methods.

Cleaning should be carried out using a validated cleaning process wherever
possible.

10.2.2 Manual Cleaning (see flowchart page 10)

10.2.3 Automated Cleaning (see flowchart page 11)
Effective cleaning is an essential prerequisite to all subsequent methods of decontamination.
Automated cleaning is a controlled process that will provide more consistent results and therefore
manual cleaning of items should only be undertaken when automated methods are inappropriate
or unavailable.
Automated or mechanical cleaning can be undertaken by means of ultrasonic washers or thermal
washer disinfectors.

Page 7

List of automated cleaners

o
o
o

Ultrasonic cleaner this is not a disinfection processes

Washer disinfector
Thermal washer disinfector - The use of an automated thermal washer-disinfector
provides disinfection using moist heat.

Good practice points for ultrasonic cleaners

Staffs are trained and competent in the use of the ultrasonic cleaner
Staff must wear PPE at all times when performing decontamination processes
Ensure joints and hinges are fully open
Fully immerse in cleaning solution to ensure all surfaces come into contact with the
solution
Do not overload the basket
Do not overlap instruments
Do not place instruments on the floor of the ultrasonic cleaner
Do not operate with the lid off
Do not put hands into the tank of the ultrasonic cleaner while the machine is in use

Good practice points for washer disinfectors

Staffs are trained and competent in the correct use of the WD, (including testing of the
equipment)
Decontaminate hands prior to commencing the process
Wear PPE for the task being undertaken
Decontaminate hands following the cleaning process and removal of PPE.
Check instruments thoroughly for cleanliness and functionality and dispose of any that
are damaged, blunt or show signs of corrosion.
Maintain good housekeeping by cleaning the area as you go.
Ensure decontamination equipment is kept clean.

Page 8

Approved Agents for Automated Cleaning

Product
(Recommended Name)

Proprietary Name

Usage

General purpose
(neutral)

Hospec

For manual immersion and nonimmersion cleaning, environmental

cleaning and patient associated
equipment cleaning.

Detergent impregnated wipes

Tuffie detergent wipes

For horizontal surfaces, nonimmersion cleaning and patient

associated equipment

Bactericidal detergent

Johnson Diversity D2

For dishwashing by hand.

Enzymatic detergent

Ultraclean

Used in ultrasonic washers for

cleaning of medical instruments

detergent

Sonozyme
Used in washer disinfector for
endoscopes

Page 9

10.2.2 Manual cleaning flowchart

Cleaning

Manual
Immersion

Equipment Required: o A sink/receptacle (not a hand wash basin) to ensure full

immersion of the equipment
o A warm detergent solution as per manufacturers
instructions
o Disposable clean cloths
o A clean non-shedding cloth or disposable paper towels
o Personal Protective Equipment (PPE) i.e. disposable
gloves, aprons and goggles/face visors
Procedure: o Decontaminate hands prior to donning PPE
o
o Fill sink/receptacle with warm water (<35 C) and detergent
o Immerse the item ensure to displace trapped air
o Brush, wipe, agitate or irrigate the items to dislodge and
remove visible dirt
o Remove items and drain them over the detergent solution
o Rinse items in clean water
o Remove items to drain
o Carefully hand dry using absorbent non-shedding cloth
o PPE should be removed and disposed of in clinical waste.
Hands must be washed after this procedure

Non-Immersion

Equipment Required: o
o A warm water (<35 C) detergent solution
o Disposable clean cloths
o A clean disposable non-shedding cloth
o PPE, disposable gloves and aprons

Procedure: o If equipment is electrical ensure that it has been disconnected from

the mains supply before cleaning
o Decontaminate hands prior to the donning of PPE
o Immerse the clean cloth in the detergent solution and wring out
thoroughly
o Commence with the upper surface of the item, wipe thoroughly
ensuring that detergent solution does not enter electrical components
o Periodically rinse the cloth in clean water and repeat as above
o Surfaces should be hand dried.
o NB the above procedure may be performed using detergent
impregnated wipes, however, check with the manufacturers
instructions
o PPE should be removed and disposed of in clinical waste. Hands
must be washed after this procedure

Page 10

10.2.3 Automated cleaning flowchart

Automated Cleaning

Thermal Washer Disinfectors

(WD)
This process incorporates both
cleaning and disinfection.

Procedure: o Decontaminate hands prior to donning

PPE.
o Follow manufacturers instruction for
details on operating the WD.
o Ensure instruments, bedpans and
other equipment is compatible with the
process and detergents used.
o Ensure items are loaded correctly and
any hinged or jointed items are open.
o Items that require irrigation must be
attached correctly to the irrigator.
o Ensure the action spray is not being
obstructed by items needing cleaned.
o After the cycle is completed check
items thoroughly for visible soiling.
Reprocess any item that remains
contaminated.
o Complete the documentation recording
the items that have been processed.
o PPE to be disposed of in clinical
waste.
o Hand decontamination must be
performed after removal of PPE.

Ultrasonic cleaners

Equipment requirements: - preliminary

essentials prior to using the ultrasonic
washer. Follow manufacturers instructions.
o Ensure that the ultrasonic washer is
clean and dry prior to use.
o Fill the reservoir with potable water
(drinking quality) to the designated line
and replace the lid.
o Switch on and leave for the required time
to de-gas the water adhering to the
manufacturers instructions.
o Switch off

Procedure: o Decontaminate hands prior to donning PPE.

o Follow the preliminary essentials as above.
o Remove the lid and add a suitable enzymatic
detergent that is effective at low temperatures.
o Set the timer control to the specified time.
o Carefully immerse the item ensuring displacement of
any air.
o Irrigate lumened/cannulated devices.
o Replace lid and switch on for the recommended
duration.
o Switch off, open lid and remove the items and drain.
o Transfer to a clean rinse receptacle.
o Rinse thoroughly with clean potable water ensuring
irrigation of lumened/cannulated areas, drain.
o Carefully hand dry using absorbent, non-shedding
cloth.
o Inspect item(s) for visible contamination, reprocess if
this is evident.
o After use the ultrasonic cleaner should be drained,
cleaned, dried, covered and stored dry until required
for re-use.
o Complete the documentation recording the items that
have been processed.
o PPE to be disposed of in clinical waste.
o Hand decontamination must be performed after
removal of PPE.
Page 11

Chapter 10 Decontamination
10.2.4 Equipment cleaning table

All equipment used for patient care must be adequately decontaminated and stored
correctly between uses.
Selection of the appropriate decontamination procedure demands an understanding of the
level of decontamination required.
The principles of decontamination can be found in chapter 10.1.

Page 12

DECONTAMINATION OF COMMONLY USED PATIENT EQUIPMENT

THIS LIST IS NOT EXHAUSTIVE
CLEANING: Use a solution of neutral liquid detergent and warm water, rinse and dry. For smaller items, a pre-impregnated detergent wipe
may be used.
EQUIPMENT OR
SITE

PROCEDURE

COMMENT

RESPONSIBILITY

Airway/ endotracheal
tube

Single use.

Ambu-lifts

Clean between patients and when

visibly soiled.

Infected/immunosupressed patients or patients with Clinical staff

blood/open wounds present; Clean then disinfect
with 0.1% Hypochlorite solution.

Ampoules single
dose

Wipe neck with 70% alcohol prior to

opening.

Ampoules to be handled by scrubbed-up staff must Clinical staff

be sterile. Do not store in disinfectant or alcohol.

Clinical staff

Ampoules multi dose Before use, check that the cap and
bung are intact and that the solution is
clear. Disinfect the rubber diaphragm
with 70% isopropyl alcohol before
use.

Discard any vial 4 weeks after its first use. Also Clinical staff
discard any vial after the bung has been pierced 5
times.

Auroscope specula
(ear piece)

Single use disposable preferred.

Clean between each patient use.

Aprons

Single use disposable.

White for clean work eg serving meals, administering Clinical staff undertaking
medications. Coloured for potentially contaminating cleaning procedure
activities eg wound dressings, decontaminating
equipment etc.
Domestic Staff in accordance
(See local protocol for colour coding of aprons In with National Colour Coding
ITU).
Policy

When injections are being made into a body cavity

eg local anaesthetic into the epidural space, use a
single dose vial.

Clinical staff

Page 13

EQUIPMENT OR
SITE

PROCEDURE

COMMENT

RESPONSIBILITY

Baby Bottles/teats

Pre-packed single use.

Baby scales

Protect from soiling with paper roll. If soiled or baby is known infected, clean then Clinical staff
Renew between each use and clean disinfect.
daily.

Sanitary ware

Clean after each patient use.

If mothers wish to use their own bottles etc, then the Clinical staff
bottles and teats should be rinsed in cold water to
get rid of all traces of milk. Bottles should then be
washed in neutral liquid detergent and warm water,
rinsed and totally immersed in a solution of
Hypochlorite 0.015% (140 ppm available chlorine) for
30 minutes and allowed to dry inverted. The tank
should be emptied daily, washed in warm water and
neutral liquid detergent, rinsed, and dried thoroughly
with a paper towel before refilling.

Infected/immunosupressed patients or patients with Domestic staff - daily, Nursing

blood/open wounds present- clean then disinfect.
staff - between patient use
Taps and appliances which are not used at least Department Managers
once per week are identified and flushed once per
week for a period of 5 minutes (see Legionella
Policy).

Routine Cleaning

Domestic Staff in accordance

with local work schedules
Infected/immunosupressed patients or patients with Clinical staff
blood/open wounds present - clean then disinfect.

Bath Hoists

Clean after each use.

Bath water

Antiseptics should not be added

routinely to bath water.

Bed Frames (back

rest, foot rest)

Clean after each use, when soiled and Infected/immunosupressed patients or patients with Domestic staff bed frames daily
on patient discharge.
blood/open wounds present - clean then disinfect.
Nursing staff, when soiled and
on discharge of patient.

Only use when prescribed.

Clinical staff

Page 14

EQUIPMENT OR
SITE
Bed base
& wheels
Including cots

PROCEDURE

Clean weekly, when soiled and on

patient discharge.

COMMENT

RESPONSIBILITY

Infected/immunosupressed patients - clean then Underside downwards of bed

disinfect with 0.1% hypochlorite solution.
base domestic staff weekly.
Top side of bed base, (below
mattress) clinical staff weekly,
when soiled and on discharge of
patient.
(Note in the absence of
domestic service availability, the
bed in its entirety should be
decontaminated by clinical staff)

Bed tables and

underside of table

Clean.

Infected/immunosupressed patients - clean then Domestic staff daily

disinfect with 0.1% hypochlorite solution.
Nursing staff, when soiled and
on discharge of patient

Bed Pans
(disposable)

Use macerator as instructed.

If not available, empty contents down sluice or toilet Clinical staff

and dispose of as clinical waste.

Bed pans
(re-usable)

Use bed pan washer disinfector.

If not available, empty contents down sluice or toilet, Clinical staff

clean then disinfect with 0.1% hypochlorite solution.

Bed pan Carriers

Clean and store in designated racks.

Bins

Clean with detergent and warm water,

rinse and dry.

Infected/immunosupressed patients - clean then Clinical staff

disinfect with 0.1% hypochlorite solution.
If used within isolation room, clean then disinfect with Domestic staff
0.1% hypochlorite solution.

Bowls (patient wash)

Use washer disinfector where

available.
Manually clean where unavailable
Store dry and inverted above floor
level.

Infected/immunosupressed patients - clean then Clinical staff

disinfect with 0.1% hypochlorite solution.
(Discard disposable basins after each use and single
patient use basins on patient discharge.)

Page 15

EQUIPMENT OR
SITE

PROCEDURE

COMMENT

RESPONSIBILITY

Bowls (surgical)

Single use preferred.

Birthing pools

Follow manufacturers advice on Dispose of any single use accessories/hosing Clinical staff
between patients.
cleaning and maintenance.
Use single use disposable liners.
Clean then disinfect all surfaces and
outlets with a 0.1% hypochlorite
solution.

Breast Pumps

Single use disposable or treat as for

baby bottles.

Clinical staff

Carpets

Vacuum daily and wash by hot water

extraction method at least once every
six months.

Domestic staff
(Clinical staff should deal with
body fluid spillage in the first
instance) and report to Domestic
Services.

Catheter stands

Clean between patients and when

soiled.

Chairs

Clean with detergent and warm water, Wipe able fabrics should always be selected for use Domestic staff
rinse and dry.
in clinical areas.
For contaminated spillages, follow NHS Fife spillage
Clinical staff should deal with
policy.
body fluid spillage in the first
instance and report to Domestic
Services.

Commodes

Clean frame. The pan should be Infected/immunosupressed patients - clean then Clinical staff
treated as for bedpans.
disinfect with 0.1% hypochlorite solution.

Computer and other

IT equipment in
clinical areas.

Keep free from dust. Clean in Decontaminate hands after using the computer.
accordance
with
manufacturers
instructions. Use wipe able plastic
keyboard covers where available.

Re-usable, send to CSSD for Sterilisation.

Clinical staff

Infected/immunosupressed patients - clean then Clinical staff

disinfect with 0.1% hypochlorite solution

Clinical and/or administration

staff

Page 16

EQUIPMENT OR
SITE

PROCEDURE

COMMENT

RESPONSIBILITY

Crockery/ cutlery

Where possible, machine wash with a Where washing machine is not available, hand wash Kitchen staff, domestic staff or
final rinse temperature of 80C which with antibacterial detergent and warm water and clinical staff dependant on local
allows air-drying of the contents.
rinse in hot water. (The rinse water temperature policy.
should be too hot for bare hands, necessitating the
use of colour coded household rubber gloves) invert
on racks and allow to air-dry or use disposable paper
roll.

Couches
(examination)

Cover with disposable paper roll to Infected/immunosupressed patients - clean then Clinical staff
minimise contamination.
Change disinfect with 0.1% hypochlorite solution.
between patients. Clean daily or when
soiled.

Couch frame & box

Dentures

Before overnight storage, clean with

neutral liquid detergent and warm
water or toothpaste, using patients
own toothbrush.

Plug holes and

Overflows

Clean regularly.

Surgical Drains

Single use disposable.

Drip stands

Clean.

Duvets and Duvet

Covers

Domestic Staff
Store overnight in fresh water in a clean sealed Clinical staff
container (preferably disposable). Prior to use, brush
again under running water. Clean pot and store dry.

Do not pour disinfectant down the drain it is of no Domestic Staff

practical use. Ensure that taps are not run violently
as this creates spray and aerosol. Smelly drains
should be reported to the C/N or Domestic
Supervisor as applicable.

Clinical Staff

Infected/immunosupressed patients - clean then Clinical staff

disinfect with 0.1% hypochlorite solution.
Must be laundered after each patient (Ensure manufacturers instructions are consistent Clinical staff
use and if soiled, in accordance with with GP/LS prior to purchase).
Policy GP/LS Safe Handling of
Laundry.

Page 17

EQUIPMENT OR
SITE
Ear Syringe
(Propulse)
ECG Equipment

Endoscopes
Flower Vases
Furniture - General

PROCEDURE

COMMENT

Decontaminate in accordance with

NHS Fife Ear Irrigation Policy NP4.
Straps clean between patient use.
Use disposable electrodes.

RESPONSIBILITY

Clinical staff
Clinical staff

Machine clean daily or when visibly

soiled.
Sterilisation or high level disinfection
Refer to Endoscopy section of Infection Control Clinical staff
required.
Manual.
Clean.
Clean at least weekly or sooner when flowers are Clinical staff
replaced. Change water daily.
Clean.
Domestic staff
Infected/immunosupressed patients clean then Clinical staff should deal with
disinfect with 0.1% hypochlorite solution.
body fluid spillage in the first
instance
Clinical staff

Hair brushes/combs

Clean and air dry (individual use).

Hand Hygiene

Refer to Infection Control Manual

section 2.1 Hand Hygiene.

Headphones

Use single patient use earpieces.

Infected/immunosupressed patients clean then Clinical staff
Clean between patient use and if
disinfect with 0.1% hypochlorite solution.
soiled.
Disposable or sterilise. Change daily Fill only with sterile distilled water.
Clinical staff
and between patients.

Humidifiers

Incubators

When caring for patients with Clostridium Difficile All NHS Fife staff
associated disease, always decontaminate hands
with soap and water as alcohol gel has been proven
non-effective in these cases.

Non-infected patients dismantle Infected/immunosupressed patients clean then Clinical staff

according
to
manufacturers disinfect with 0.1% hypochlorite solution.
instructions and clean all parts
including the motor unit and housing. Store dry.
Reassemble and store dry. Do not
top up reservoir but clean, dry and
refill immediately before use with fresh
sterile distilled water.

Page 18

EQUIPMENT OR
SITE
Instruments

PROCEDURE

COMMENT

Surgical instruments returned directly DISPOSABLE SHARPS

RETURNED TO SSD.
to the Sterile Services (SSD).

MUST

RESPONSIBILITY

NEVER

BE Clinical staff

Do not clean instruments prior to

return to SSD.
Lancing Devices
Single use only preferred.
Where the patient has their own device, this should
be used in accordance with the manufacturers
guidance. Do not use on more than one patient.
Laryngoscope
Single use or returned directly to SSD
Blades
for sterilisation.
Linen
Refer to Infection Control Manual
Chapter 2.
Locker Tops and Clean daily or when spillage occurs.
Bedside Tables
Lockers (Interior)
Mattresses
Pillows

Medicine Cups

Clean weekly and on discharge.

Clinical staff

Clinical staff
All staff
Domestic staff daily. Clinical
staff if spillage occurs and on
discharge of patient.
Clinical staff

and Clean.

Pillows should be enclosed in heat sealed plastic Clinical staff

covers. Mattress and pillow integrity testing should
Infected/immunosupressed patients be carried out on a monthly basis. Contact your
clean then disinfect with 0.1% Infection Control Nurse for instructions if required.
hypochlorite solution.

Single use disposable or treat as for Do not wash in handwashing sink in ward.
crockery.

Moving and handling Hoist clean between patient use.

equipment
Slings and sliding sheets should
be allocated to each patient for their
individual use and then sent to
laundry for cleaning.
Nailbrushes
Single use disposable.

Clinical staff

All equipment should be cleaned between use on Clinical staff

different patients and when soiled. If the patient has
known Infected/immunocompromised, clean then
disinfect with 0.1% hypochlorite. (Single use slings
are available for certain makes of hoists).
Not to be used in ward areas. If these are required All staff
then they must be single use only.
Do not leave at sink.

Page 19

EQUIPMENT OR
SITE

Nebulisers

PROCEDURE

COMMENT

Single patient use.

Clean, rinse and
between therapies.

Oxygen Tubing

Use only sterile water and medication.

dry

Rooms
cleaning)

Scissors

Clinical staff

thoroughly Change tubing and mask weekly.

Single use.

Clinical staff

Patient
equipment Clean between different patient use Infected/immunosupressed patients, clean
stands eg IV and and when soiled.
disinfect with 0.1% hypochlorite solution.
monitor stands

Proctoscopes

RESPONSIBILITY

then Clinical staff

Single use.

Clinical staff

(terminal See Infection Control Manual Chapter In accordance with Terminal Cleaning work schedule
2 Control of the Environment.

For all dressings and sterile

procedures, use sterile disposable or
autoclavable scissors.

Clinical and
Domestic staff

Clinical staff

Shaving Equipment Razors Disposable, single patient Non-disposable (electric): Patients may only use Clinical staff
(wet shaving is use.
their own personal electric razor.
preferred)
For cleaning of this product, refer to manufacturers
instructions.
Communal electric razors should not be used.
Clippers.

Single patient use (disposable heads).

Page 20

EQUIPMENT OR
SITE
SKIN

Sphygmomanometer

Sphygmomanometer
Cuffs

PROCEDURE

COMMENT

RESPONSIBILITY

Cord stumps clean with cotton

Clinical staff
wool and warm water at every nappy
change.
Hands Refer to NHS Fifes Infection
Control Manual Section 2.1.
Injection Sites clean skin with 70%
Isopropyl alcohol (in single use swab)
and allow to dry before injection.
NB Diabetic Patients need not use
alcohol for skin cleansing when
injecting insulin.
Operation Site Chlorhexidine 0.5%
in 70% alcohol OR Povidone iodine
10% alcoholic solution (Betadine).
Pre-urinary
catheterisation
preparation Clean with 0.9%
sodium chloride available in single
use sachets.
Venepuncture sites Clean skin
with 70% Isopropyl alcohol (in single
use swab) and allow to dry before
penetrating skin.
Vulval area Warm tap water for
swabbing prior to childbirth.
Clean.
If patient has known infection/immunocompromised, Clinical Staff
clean then disinfect with 0.1% hypochlorite.

Single patient use preferred.

Ensure electronic equipment is disconnected from

mains prior to cleaning.
Clean between each patient use.
Clinical staff

If reusable, should have waterproof If patient has known infection/immunocompromised,

covers.
clean then disinfect with 0.1% hypochlorite.
Sputum Pots

Use disposables
clinical waste.

and discard as

Clinical staff

Page 21

EQUIPMENT OR
SITE
Stethoscopes

Suction Apparatus

Syringes (1)
Syringes (2)

Toys

Trolley (dressing)

PROCEDURE

COMMENT

RESPONSIBILITY

Diaphragm Wipe with an alcoholClinical staff

impregnated swab between each
patient.
Earpieces Following disconnection,
the earpieces should be cleaned.
Catheters Sterile single use.
Do not open until needed. Do not connect until Clinical staff
Tubing Disposable.
suction operating.
Connectors If contaminated, clean.
Lids (where still in use) clean.
Change daily and between patients
Filters Refer to manufacturers
instructions.
Disposable Jars/Liners Seal all
connections, place in rigid leak proof
container.
Non-disposable Take to sluice with
lid attached and tip contents down
sluice. Place in washer disinfector or
send to SSD check.
(Home care if not available, clean
then disinfect).
Plastic (Sterile) Disposable. Single
use only.
Baxa Syringes reusable for Clean.
administration of medication and
enteral feeds.
Refer to manufacturers instructions regarding
frequency of use.
Toys should be capable of being For patients with infectious diseases, the use of toys
washed or wiped clean.
should be discouraged or be destroyed after use.
Toys in regular use must be cleaned
daily. Visible soiled toys must be
cleaned immediately. Soft toys are
discouraged.
Clean daily and when contaminated.
Before and after each patient use, wipe over top
surface with 70% alcohol and allow to dry before
placing sterile pack on top.

Clinical staff
Clinical staff

Clinical staff

Clinical staff

Page 22

EQUIPMENT OR
SITE
Tympanic
thermometers

Tourniquets

Urine Bags

PROCEDURE

Handpiece clean between patients.

COMMENT

RESPONSIBILITY

If patient has known infection/immunocompromised, Clinical staff

clean then disinfect with 0.1% hypochlorite.

Earpiece single use disposable

sheath.
Single patient use preferred.
I patient has known infection/immunocompromised, Clinical staff
clean then disinfect with 0.1% hypochlorite.
Single patient use only.

Urine bag holders/

stands

Clean daily.

Urine bottles
Uniforms
Vaginal specula

See BEDPANS.
Refer to NHS Fifes Uniform Policy.
Single use preferred.

Night bags Empty contents down the sluice or Clinical staff

toilet avoiding splashing. Dispose of bag in orange
clinical waste bag.
Leg bags Empty as required and replace 5-7 days
in accordance with manufacturers instructions.
If patient has known infection/immunocompromised, Clinical staff
clean then disinfect with 0.1% hypochlorite.

Where reusable devices are utilised, send to SSD for Clinical staff
reprocessing.
Walking aids
Clean between patient use and when Dedicate for individual use.
Clinical staff
visibly dirty...
Wheel chairs (patient Clean between patient use and when Dedicate for individual use.
Clinical staff
allocated)
visibly dirty.
Wheel chairs
Clean as above
Head of any department using common wheel chairs Head of Department
(general department)
must allocate responsibility to a relevant job holder
for routine cleaning.

Page 23

Chapter 10 DECONTAMINATION
10.3 Disinfection
10.3.1 Introduction
Disinfection methods may be used to reduce the microbial flora of skin and mucous membranes i.e. hand
decontamination and pre-operative skin preparation or to reduce the microbial flora of inanimate objects,
where heat is inappropriate or cleaning alone is insufficient.
Disinfection is an individual step in the decontamination cycle, used to reduce the number of microorganisms to a level that is considered safe, but which may not necessarily destroy some viruses or
bacterial spores. It may be followed by sterilisation depending on the intended use of the device.
It is generally used to decontaminate equipment which is in contact with intact mucous membranes, body
fluids and particularly after use on infected patients or prior to use on immuno-compromised patients
Some high-risk or intermediate-risk medical devices are not able to be heat sterilised and require high
level disinfection between patients uses i.e. fibre-optic endoscopes. Practitioners who decontaminate
endoscopes must have separate guidelines for the local reprocessing of endoscopes.
Disinfection is achieved by either thermal or chemical methods (or a combination of both).
Thermal disinfection must be used in preference to chemical disinfection.
Chemical disinfection may only be used for items for which thermal disinfection methods are unsuitable.
This process must not be used for items intended for single use only.
Cleaning is a pre requisite to disinfection

Heat disinfection (see flowchart page 27)

Dishwashers, washing machines and washer-disinfectors are effective methods for disinfecting
equipment because they clean the item and then expose the items to hot water for the required time to
achieve thermal disinfection.

Chemical Disinfection (see flowchart page 27)

Physical cleaning of the device prior to chemical disinfection should always be carried out.
When to use

There should be very few reasons for using a chemical disinfectant.

They can be toxic, flammable, corrosive or have other material incompatibilities so there use
should be avoided wherever possible.
The use of chemical disinfectants is only recommended for disinfection of heat sensitive
instruments, decontamination of surfaces, making potentially infected items safe for handling
If chemical disinfection is necessary, use the method recommended by the manufacturer.

Chemical Disinfection can be of a high or a low level.

a) High level chemical disinfection is used in specialist settings for items which cannot
disinfection/sterilisation e.g. peracetic acid to reprocess endoscopes.
b) Low level chemical disinfection e.g. chlorine releasing agents or alcohol

withstand heat

Page 24

Controls of Substances hazardous to Health (COSHH)

Chemical disinfectants are often an irritant when in contact with the skin and mucous membranes or by
vapour inhalation. They can also be corrosive and flammable. A risk assessment under the Controls of
Substances hazardous to Health (COSHH) Regulations must be undertaken before a process using
chemical disinfection can be used.

There is a potential fire hazard associated with all chemical disinfectant products. It is advisable
that these products are stored in an appropriate heat resistant cupboard.

All staff using chemicals must undergo COSHH training, and must not handle the chemicals until
training is complete.

Safety data sheets for chemicals must be kept in each department

Disinfectants must be stored, reconstituted and used in accordance with COSHH regulations.

Good Practice Points

Refer to NHS Fife disinfection policy to ensure correct agent is used (not available)
Never use chemical disinfection when sterilisation is required or when cleaning alone is sufficient
Physical cleaning of the device prior to disinfection is essential as organic material inactivate
disinfectants.
Check expiry date and storage conditions of disinfectants.
Ensure disinfectants are used at the recommended concentration
Do not mix disinfectants with each other or other chemicals as gases may be produced and can
cause ill effects for the user.
When chemically disinfecting large areas, ensure adequate ventilation
Ensure that the disinfecting fluid penetrates into all crevices of the article being disinfected
Deal with spillages promptly and in accordance with COSHH data sheet (see IC manual section
2.6)
Equipment must never be stored in a chemical disinfectant.
NEVER use alcohol based disinfectants in the presence of diathermy or other sources of ignition.
Do not, under any circumstances, decant disinfectants/detergents/cleaning agents from one
container to another
Ensure all associated equipment is stored clean and dry
Do not use chlorine preparations on urine as they may release chlorine vapour which is
dangerous to the user

Page 25

NHS Fife Approved Disinfectants

Product
name)

(recommended Proprietary
Name

General purpose detergent

Chlorine releasing agents
Sodium hypochlorite solution

Hospec
Titan sanitizer
Milton

Sodium dichlorisocyanurate

Actichlor

Peracetic acid
Isopropyl alcohol 70%

Perasafe
Isopropyl alcohol
70%
Alco
wipes,
Mediswabs
and
Azowipes
Virkon

Isopropyl
alcohol
impregnated swabs

70%

Peroxygen Compound
(For Restricted Use)
Chlorhexidine

Iodine

2% Chlorhexidine Gluconate
in 70% Isopropyl alcohol
Triclosan

Hibiscrub, Hibisol,
Unisept
and
Hydrex
Betadine, inadine
and
Povidine
iodine
ChloraPrep
Skinsan

Usage
Pre-cleaning prior to disinfecting
For toilet and sink use
Infant feeding bottles and food preparation
areas.
Patient
environment
and
associated
equipment. (1,000 ppm 0.1%)
Blood Spillages (10,000 ppm 1%)
Heat labile endoscopy
For hard horizontal surfaces
Decontamination of the skin prior
venepuncture and vascular cannulation

to

Laboratories and the mortuary

This is used as a skin and hand disinfectant
only
For skin disinfection prior to surgery and for
the treatment of small wounds.
For skin disinfection prior to CVC insertion and
aftercare
Hand and skin disinfectant

Page 26

10.3.2 Disinfection flowchart

Disinfection

Chemical

Heat

Equipment required: o Dishwashers, washing machines

and washer- disinfectors
o Ensure the items being disinfected
in this manner will withstand
repeated exposure to wet heat at
o
temperatures of 80 C

Procedure: o Ensure the thermal disinfector that

you are using is fit for purpose.
o The disinfector must be able to
clean the item and expose the item
to hot water for the required time.
o Decontaminate hands prior to
donning PPE.
o Where practicable ensure debris is
removed from items before they
are processed.
o Complete documentation.
o Remove PPE and dispose of into
clinical waste.
o Decontaminate hands after
removing PPE.

Full Immersion Method

Equipment required following the
cleaning process: o A solution of freshly prepared
chemical disinfectant at the correct
dilution.
o PPE
o Disposable
absorbent
nonshedding cloths

Procedure: o Decontaminate hands prior to donning

PPE
o Fill the receptacle with the prepared
chemical solution.
o Carefully immerse the item fully to ensure
displacement of trapped air.
o Place lid on the receptacle and leave for
the recommended time.
o Remove the item from the solution drain
into the solution.
o Rinse thoroughly with sterile water,
ensuring recontamination does not occur.
o Carefully dry the item by hand using an
absorbent non-shedding cloth.
o Complete documentation.
o Thoroughly wash and dry receptacle
before storing in a clean area.
o Remove PPE and dispose of into clinical
waste.
o Decontaminate hands after removing PPE.

Non-Immersion Method
Equipment required following the
cleaning process: o A solution of freshly prepared
chemical disinfectant at the correct
dilution.
o PPE
o A clean disposable absorbent nonshedding cloths

Procedure: o Decontaminate hands prior to donning

PPE
o Fill the receptacle with the prepared
chemical solution.
o Immerse the clean cloth into the
disinfectant solution and wring thoroughly.
o Wipe down the item followed, by rinsing
the disinfectant residue from the item and
the dry with an absorbent non-shedding
disposable cloth.
o Rinse thoroughly with sterile water,
ensuring recontamination does not occur.
o Carefully dry the item by hand using an
absorbent non-shedding cloth.
o Complete documentation.
o Thoroughly wash and dry receptacle
before storing in a clean area.
o Remove PPE and dispose of into clinical
waste.
o Decontaminate hands after removing
Page 27PPE.

Chapter 10 Decontamination
10.4.1 Sterilisation
10.4.2 Introduction
Sterilisation is a process used to render an object free from all viable micro-organisms including viruses
and bacterial spores, e.g. used for all equipment which is to be introduced into a sterile body area. It
does not destroy prions.
Moist heat sterilisation using steam under pressure is the preferred method and it should always be used
in preference to other methods since it is more reliable, and the process can be effectively validated.
Steam sterilisation is the established method of choice for sterilisation in healthcare services. For most
reusable items this is usually done by heat using an autoclave.
Use of a Central Sterilising Service Unit should be employed wherever possible.
Where benchtop steam sterilisers are used this should only be carried out in accordance with national
guidance.
Care must be taken to use the type of steriliser which has been designed and validated for the particular
load.
At the end of the sterilisation process, a device can be considered either "sterile" or "sterilised"
depending on the process undertaken.
o
o

Vacuum sterilisers render the instrument(s) sterile.

Benchtop bowl and instrument(s) sterilisers render the processed products sterilised.

There are 2 main types of steam sterilisers:

1. Vacuum sterilisers (wrapped instrument) Type B and some Type S. The device(s) are wrapped
prior to sterilisation and after the process, the product remains wrapped until point of use.
2. Benchtop bowl and instrument(s) sterilisers (unwrapped instruments) Type N. The device(s) are
processed unwrapped however sterility is not maintained once the cycle is completed. Unless
used immediately after sterilising the device(s) are only clean at point of use.

Note: NHS Fife use only bench top bowl & instrument sterilisers.

10.4.3 Local Decontamination Unit Specific

Responsibilities
The NHS Scotland Code of Practice for the Local Management of Hygiene and Healthcare Associated
Infection (Scottish Executive, 2004) supports action to reduce the risk of healthcare associated infection
(HAI) for patients, staff, visitors and wider public at local level. Success is dependent on a change in
culture where infection control is truly everybodys business with a clear focus on the importance of good
hygiene, infection control practice and education. Service Users, staff and visitors each have an individual
responsibility to ensure a safe, effective and clean medical and surgical devices that are to be used on
patients within the healthcare setting. All staff has a responsibility within the organisation and must

Page 28

support its commitment to HAI control and reduction.

Introduction: Responsibilities

See NHS Fife Infection Control Manual

Senior Manager Decontamination (HDL (2001)10

Overall responsibility for risk assessment and management processes relating to decontamination of
reusable medical devices

Infection Control Team

Provide advice and guidance too clinical and non-clinical staff on best practice in all aspects of infection
control, including decontamination.

The Microbiologist (Steriliser)

The Microbiologist (Steriliser) advises on and audits microbiological aspects of decontamination including
washer-disinfectors and sterilisation.
Arranges for the culture of biological indicators where used.

The Authorised Person (Sterilisers)

Provide independent and impartial advice on purchasing and use of decontamination equipment
(sterilisers/washer-disinfectors)
Undertake audit of validation and periodic testing and maintenance of decontamination equipment.

Estates and Facilities Manager

Ensure organisation-wide facilities and services are compliant with national standards, statutory
requirements and other guidance;
Designs and commissions capital schemes which reflect best practice for decontamination
Provides technical advice on purchase, installation and operation of decontamination equipment
and engineering services.

Test Person (Sterilisers)

Performs the validation and periodic testing of sterilisers and washer disinfectors

Maintenance Person (Sterilisers)

Performs the planned and breakdown maintenance duties on sterilisers and washer disinfectors

Competent Person (Pressure Vessels)

Performs the statutory annual inspection of pressure vessels.

User(s) have legal responsibilities (often departmental manager and may not be the person who operates
the steriliser).

Responsible for day to day operation of the steriliser

Ensures all personnel receive training on decontamination equipment and processes
commensurate with work activity
Ensures that validation and periodic testing of equipment is carried out;

Page 29



Is trained in decontamination
Maintains staff training and decontamination equipment records

Operator (must be trained and competent in the use of the steriliser)

Prepares devices prior to processing in steriliser;

Manually cleans devices where necessary
Inspects devices for cleanliness
Replenishes reservoir with sterile water (for irrigation) from unopened container
Loads and operates steriliser;
Checks sterilisation cycle is satisfactory;
Performs the daily/ weekly checks of decontamination equipment
Transfer cleaned and dried items from the inspection area.
Completes records of loads processed, temperature checks and tracking of the processed
equipment.

Daily Checks (operator)

Ensure steriliser is clean and free from dust/debris, inside and out.
Carry out Automatic control tests, (Operate a normal cycle with an empty chamber. Record time,
temperature and pressure to ensure they meet requirements) record any faults in the log book and report
to User/Estates and Facility Managers.

Weekly checks (operator)

As for daily checks
Clean door seal and examine to ensure it is undamaged
Door interlock monthly, quarterly and annual testing will be carried out by Maintenance and test persons.

Unwrapped Instruments and Utensil Steriliser (Bowl and Instrument Steriliser)

This type of steriliser is used to process unwrapped surgical instruments and utensils intended for
immediate use in a controlled medical environment and is achieved by direct contact of the product with
saturated steam at a temperature of 134-137*C for a minimum holding time of 3 minutes.
This type of steriliser is none as non-vacuumed and should not be used to process wrapped instruments
and components, or unwrapped instruments / utensils with narrow lumens.

Pre Sterilisation requirements

Used devices must be transported safely from the clinical area to the decontamination room, in solid
sided leak proof lidded containers, which are clearly marked contaminated If they are transported
through public areas, they must also be secure.
Used instruments generated from domiciliary visits must be transported in a solid sided leak proof
container with fitted lid. This should be clearly labelled for those containers carrying separately clean and
dirty instruments.
Effective cleaning of devices prior to disinfection or sterilisation is essential in reducing the risk of
transmission of infectious agents. If devices are not clean they cannot be sterilised (see section 10.2)
Steam quality in the chamber is required to meet the specification for pyrogen free

Page 30

clean steam (set out in HTM 2031) this can be achieved using either sterile water for irrigation (from a
freshly opened container) or freshly produced reverse osmosis (RO) water.
Water should be changed at a minimum of daily intervals and the reservoir should be drained rinsed with
sterile water for irrigation and left dry overnight and when not in use.

Maintenance, testing and Record Keeping

In order to quality assure the process, the steriliser must be able to record pressure and temperature
achieved during the sterilising cycle via a process verification recorder. This information should act as a
permanent record. It is essential therefore that daily, weekly, quarterly and annual testing is performed
and recorded in a steriliser log book to ensure all validated parameters for the steriliser are met. These
records should remain with the steriliser at all times.
keep a record of all testing, maintenance and repairs
keep permanent records of every sterilisation cycle
keep permanent records of each cycle load which is used to track medical devices through
the decontamination process

ensure that there is valid Pressure Vessel Insurance Certificate (this is a legal

requirement.


Storage and Transportation
Device storage

Storage facilities for sterile and sterilised products should be secure and out with the
decontamination room.
Sterile devices and sterilised devices must be stored separately to prevent the risk of confusion
Only devices that were sterilised as wrapped items may be stored and used as a sterile device
Immediately after sterilisation, unwrapped sterilised devices should be examined visually for
dryness and, if necessary, should be dried. They should be wrapped/bagged to prevent gross
contamination in clean, unused, sterilisation grade wrapping material and be clearly marked
sterilised only
Devices must be stored in dedicated clean, dry dust free containers, whether wrapped or bagged
Stored devices should be used in strict date order i.e. first in, first out
Used devices should be stored safely in solid sided leak proof lidded containers and should be
stored for the minimum possible time before being cleaned and disinfected.

Transportation

Sterile and sterilised devices must be transported in clean dry conditions which prevent damage
to the devices and their packaging, and prevent contamination.

Page 31

Good Practice Points

Do not process wrapped, tubular or textile products in a non-vacuumed benchtop steam steriliser
All items must be clean and dry before loading into the steriliser.
Do not overload the steriliser
Arrange load items to support the removal of air and the penetration of steam
items such as bowls should be placed on their sides so that air will be displaced and
condensation can drain out.
Do not allow items to rest on the bottom of the chamber
Drain and clean chamber and reservoir at the end of each day and leave dry
All decontamination procedures should be undertaken by qualified trained competent staff,
wearing the correct PPE for the process being performed.
Care must be taken when handling loads as they may still be very hot
Care must be taken when handling loads to prevent recontamination
Unwrapped items are exposed to the air at the end of the cycle and subject to rapid
recontamination. They should be used immediately (i.e. opening the steriliser door should be
regarded as equivalent to opening a sterile pack).
Do not sterilise single-use medical devices
Do not operate equipment if you have not been trained

Page 32

Chapter 10 Decontamination
10.5 Documents
The following list of NHS Fife policies should be should be seen as guidance and considered
along with the specific policies and procedures for decontamination,
Policy No. GP1
Policy No. GP5
Policy No. GP6
Policy No. GP7
Policy No. GP10
Policy No. GP15
Policy No. GP20
Policy No. GP22
Policy No. GP24
Policy No. GP26
Policy No. GP41
Policy No. E2
Policy No. E5
Policy No. E7
Policy No. E10
Policy No. E14
Policy No. GP/P4
Policy No. H2
Policy No. IC-02
Policy No. N4
Policy No. P1
Policy No. W8

Incident Management Policy

Work Environment
Hot Water Management
Needlestick and Sharps (see N4)
Electrical Safety
Manual Handling
Risk Assessment
COSHH
Safe and Effective Use of Benchtop Sterilisers
Electro-Medical Equipment Management(see E2)
Non NHS Fife Equipment Policy
Electro Medical Equipment Management (see GP26)
Electrical Safety Policy
Policy for Environmental Audit Infection Control
Decontamination of Equipment prior to Inspection, Service or Repair
Equipment Procurement Policy
Personal Protective Equipment (PPE)
Notification of Hazards
Risk Assessment for TSE Agents including CJD and vCJD
Needlestick & Sharps Policy (see GP7)
Personal Protection Clothing
Waste Management

1. REFERENCES

Equipment Manufacturers Documentation with regards to operation including use of

recommended chemical cleaning additives, testing and maintenance, and health and safety
requirements.
Control of Substances Hazardous to Health (COSHH)
DB 2006(04) Single-use Medical Devices: Implications and Consequences of Reuse
DB 2006(05) Managing Medical Devices
HPS Endoscope Reprocessing: Guidance on the Requirements for Decontamination
Equipment, Facilities and Management (2007)
Health and Safety at Work Act (1974)
HPS Local Decontamination Units: Guidance on the Requirements for Equipment, Facilities
and Management (2007)
Management of Health and Safety at Work Regulations (1999)
The risk management of HAI: A methodology for NHSScotland (2008)
MDA Device Bulletin 9605: The Purchase, Operation and Maintenance of Benchtop Sterilizers
MDA Device Bulletin 9607: Decontamination of Endoscopes
National Health Service in Scotland Decontamination Guidance version 1 (1999)
NHS CMO (2007) 5 Important advice for dentists on re-use of endodontic instruments and
variant Creutzfeldt-Jakob disease (vCJD)
NHS HDL (2001)10 Decontamination of Medical Devices

Page 33

NHS HDL (2001)53 Managing the Risk of Healthcare Associated Infection in Scotland
NHS HDL (2001)66 Healthcare Associated Infection: Review of Decontamination
NHS HDL (2005)10 Decontamination compliance in primary care
NHS HDL (2006)45 Decontamination treatment of patients in the independent healthcare
sector
NHS MEL (1998)47 Advisory Committee on Dangerous Pathogens (ACDP) / Spongiform
Encephalopathy Advisory Committee (SEAC)
NHS MEL (1999)65 Variant Creutzfeld Jakob Disease (vCJD): Minimising the Risk of
Transmission
NHSScotland: Sterile Services Provision Review Group: 1st Report (The Glennie Framework)
(2001)
Pressure Systems Safety Regulations (2000)
Provision and Use of Work Equipment Regulations (1998)
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) (1995)
Scottish Health Technical Memorandum 2010: Sterilisation (Parts 1 6)
Scottish Health Technical Memorandum 2025: Ventilation in Healthcare Premises (Parts 1 4)
Scottish Health Technical Memorandum 2030: Washer Disinfectors (Parts 1 3)
Scottish Health Technical Memorandum 2031: Clean Steam for Sterilisation
The Decontamination of Surgical Instruments and other Medical Devices (2001)
Workplace (Health, Safety and Welfare) Regulations (1992)
The Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations
2007 (SI 2007/1573)

Page 34

0001234

DECLARATION OF DECONTAMINATION STATUS

Prior to the Inspection, Servicing, Repair or Return of Medical and Laboratory Equipment
Sent from:

Sent to:

I confirm receipt of this equipment in clean condition

Signed.
Date..
Recipient Job Card No:

Sender Order No:

Make and Description of Equipment:

Model/Serial/Batch No:

*Inspection/Servicing/Fault (please specify):

PART A
Initial box A if applicable otherwise complete all of part B
This equipment has not been used in any invasive procedure or been in contact with blood,
other body fluids, respired gases, or pathological samples. It has been cleaned in preparation
for inspection, servicing, repair or transportation.
PART B
Has this equipment/item been exposed internally or externally to hazardous materials as indicated?
If YES, provide details
Blood, body fluids, respired gases *YES\NO
Pathology samples *YES\NO
Other Biohazards *YES\NO
Chemical or substances hazardous to health *YES\NO
Other hazards *YES\NO
Has this equipment/item been cleaned and decontaminated, and all loose accessories removed?

Indicate the methods and materials used

(and methods to be used if further soiling is found)

*YES\NO
If the equipment/item could not be decontaminated
please indicate why:

Such equipment must not be sent without the prior agreement of the
recipient whose reference or contact name is given above

Has the equipment/item been suitably prepared to ensure safe handling/transportation?

I declare that I have taken all reasonable steps to
ensure the accuracy of the above information, in
accordance with HSG (93) 26

Authorised signature
___________________________
Name (printed)
___________________________

Position __________________________
Unit

__________________________

Dept

__________________________

Phone
Date

__________________________
__________________________

* Delete where not applicable

Top copy (White) attach to item/ Second copy (Yellow) send to recipient/Third copy (Pink) retain

*YES\NO